THE DOCTOR'S WORLD

THE DOCTOR'S WORLD; C.D.C. Team Tackles Anthrax

Published: October 16, 2001

(Page 3 of 3)

Mr. Blanco developed a fever, severe pneumonia involving at least two lobes of his lungs, and bloody fluid in the pleural lining. He needed a mechanical respirator to help him breathe. B. anthracis has not been identified in cultures of the fluid and sputum. His symptoms are atypical for inhalation anthrax, and there may be no way of knowing if his symptoms were caused by anthrax, Dr. Hughes said. Blood tests taken over the next few weeks to detect antibodies to anthrax and other infectious agents may help clarify the diagnosis. Meanwhile, Mr. Blanco is recovering.

Epidemiologists talked to Mr. Blanco to learn everything he did for the preceding two to three weeks. Was he an avid gardener like Mr. Stevens? Did they share a garden plot? Had they bought fertilizer or bone meal from the same distributor? What, if anything, did Mr. Blanco and Mr. Stevens do together outside work?

Because Mr. Stevens and Mr. Blanco were co-workers, epidemiologists asked about recent construction or renovation at American Media. Could someone have dug up soil that contained spores from a cow that died of anthrax many years ago?

They swabbed dust in cracks, under the desks and from ventilation ducts and filters. Anthrax spores were found on Mr. Stevens's keyboard. Spores also were detected in samples from work surfaces in the mailroom at American Media, the C.D.C. said.

The exercise was repeated several times, after anthrax was identified in other people.

Anthrax was cultured from the nose of Stephanie Dailey, 36, who worked with Mr. Blanco in the mailroom. Then attention turned to New York City when Erin M. O'Connor, an assistant to Tom Brokaw at NBC headquarters, developed cutaneous anthrax after opening two envelopes, one containing powder and the other a granular substance.

The initial skin lesions from anthrax can resemble an insect bite, and a doctor who examined Ms. O'Connor initially thought she might have been bitten by a brown recluse spider, Dr. Hughes said. Luckily, however, an infectious disease specialist who had worked in areas of the world where anthrax is endemic suspected it was the cause of the sore on her skin and a dermatologist then took a biopsy of the lesions and sent a sample to the C.D.C.

Special staining and immunologic tests performed at the centers identified anthrax as the cause of the skin lesion, but the organisms have not grown in the laboratory, presumably because the antibiotics Ms. O'Connor had already been taking destroyed them, Dr. Hughes said.

Tests on Ms. O'Connor's biopsy were among thousands of others that C.D.C. and state and local health laboratories have performed in the search for the source of the anthrax.

Cultures from swabs of noses and environmental sources may grow several microbes. So scientists may have to repeat the tests before they can confirm anthrax. Newer laboratory techniques based on DNA, like the polymerase chain reaction, have allowed more rapid detection of microbes. But such successes have also created overly optimistic expectations. When it is necessary to grow microbes in the laboratory, the process cannot be speeded up, Dr. Kop lan said.

In recent years, many public health leaders have warned that the country was ill prepared to detect anthrax and other diseases that only a few American doctors have seen. Yet the quick detection of anthrax in New York and Florida suggests that doctors may be better prepared than expected to respond to the threat, Dr. Koplan said.

Dr. Martin E. Hugh-Jones, an anthrax expert at Louisiana State University, said: ''Official agencies have learned they must talk to each other. We've for years been trying to get doctors to understand what to look for. Now everyone knows.''

Photos: Employees of American Media waited to be tested for anthrax exposure last week in Delray Beach, Fla., after an infected co-worker died. (Gary I. Rothstein for The New York Times)(pg. F7); Dr. Alexander D. Langmuir, the first director of the Epidemic Intelligence Service of the Centers for Disease Control, helped establish guidelines for tracking outbreaks. But he also emphasized communicating the results to the public. (Associated Press); To determine the source of an outbreak, investigators take samples from the environment. These health workers are removing materials from the office where Mr. Stevens worked. (Agence France-Presse); In some cases, medical sleuths work in concert with law enforcement officials. A firefighter, right, decontaminates an investigator from the F.B.I. (Agence France-Presse); Dr. John Agwunobi answers questions about the investigation in Palm Beach County at a press conference. Some experts say too few public health officials have been willing to talk to the press.; Bacillus anthracis (Photo Researchers); (Associated Press)(pg. F1) Chart: ''The Hunt for Clues'' On Oct. 4, doctors determined that Robert Stevens of Lantana, Fla., had contracted inhalation anthrax. Concerned about the possibility of bioterrorism, health officials from federal, state and local agencies embarked on a standard series of steps to pinpoint the source of the anthrax. THE PATIENT Send epidemiologists to trace evolution of patient's illness by talking with doctors, patient and family. In the Stevens case, the Centers for Disease Control and Prevention dispatched 15 investigators to Florida and to North Carolina, where Mr. Stevens had been visiting his daughter. THE TIMELINE Reconstruct patient's travel, work and leisure activities over the likely period of incubation. The normal incubation for inhalation anthrax is one to seven days; the C.D.C. retraced Mr. Stevens's previous two weeks. THE ENVIRONMENT Collect samples of air, dust and objects from home, workplace and other areas patient visited. Anthrax spores were found on Mr. Stevens's keyboard at work. THE HOSPITALS Canvass doctors, hospitals and local health authorities for similar cases that may have been misdiagnosed, and set up system to report any new cases. A co-worker is found to have anthrax spores in his nose. THE HYPOTHESIS Construct theories based on information collected and results of laboratory tests. In the Florida case, the C.D.C. says evidence supports the hypothesis that the anthrax was introduced through the mail. (pg. F1)